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Rev Senol Patol Mamar. 2020;xxx(xx):xxx---xxx

Revista de Senología
y Patología Mamaria
www.elsevier.es/senologia

SPECIAL ARTICLE

Diagnosis and locoregional treatment of patients with

breast cancer during the COVID-19 pandemic
Ricardo Pardo a,∗ , Manel Algara b , María Angeles Montero-Fernández c , Xavier Sanz b ,
Mar Vernet d , Nuria Rodríguez b , Rogelio Andrés-Luna e , Antoni Piñero f ,
Raquel Ciérvide g , Raúl Córdoba h , Rajiv V. Dave i , Ángel Montero g , Irene Osorio a ,
Nuria Argudo d , Sergio Salido a , Juan Bernar a , Susan Pritchard c , Natalia Frade Alves e ,
Pau Nicolau d , Pilar Orihuela a , Marta Jiménez d

a
Breast Unit, General Surgery Department, Fundación Jimenez Díaz University Hospital, Madrid, Spain
b
Radiation Oncology Department, University Hospital del Mar, Barcelona, Spain
c
Histopathology Department, Manchester University NHS Foundation Trust, UK
d
Breast Unit, University Hospital del Mar, Barcelona, Spain
e
Breast Unit, University Hospital Santa María, Lisboa, Portugal
f
Breast Unit, University Hospital Virgen de la Arrixaca, Murcia, Spain
g
Radiation Oncology Department, HM Hospital Sanchinarro. Madrid, Spain
h
Clinical and Organizational Innovation (UICO), Quironsalud Public Hospitals, Madrid, Spain
i
Breast Unit, Nightingale Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, UK

Received 29 April 2020; accepted 30 April 2020

KEYWORDS Abstract We are facing a pandemic that is going to affect a significant part of the population.
Breast cancer; At the end of April in the world there are about 3,000,000 cases, with 205,000 deaths and
COVID-19; 860,000 patients recovered.
Locoregional The response to this pandemic has in many cases led to a significant change in the daily
treatment; work of caring for cancer patients, the good results of which depend largely on time-adjusted
Surgical and protocols and multidisciplinary treatments.
radiotherapy We present a review of local, surgical and radiotherapy treatment together with authors’
treatment recommendations made from personal experience on ways to act in the diagnosis and surgical
treatment of breast cancer during the COVID-19 pandemic.
The multidisciplinary Breast Committees must continue to meet weekly in videoconference
format. All surgical actions and irradiations must be carried out with maximum safety for both
the patients and the participating teams. Hypofractionation in radiation therapy should be the

∗ Corresponding author.
E-mail address: rpardo133@yahoo.es (R. Pardo).

https://doi.org/10.1016/j.senol.2020.04.002
0214-1582/Published by Elsevier España, S.L.U. on behalf of SESPM.

Please cite this article in press as: Pardo R, et al. Diagnosis and locoregional treatment of patients with breast cancer
during the COVID-19 pandemic. Rev Senol Patol Mamar. 2020. https://doi.org/10.1016/j.senol.2020.04.002
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SENOL-261; No. of Pages 7 ARTICLE IN PRESS
2 R. Pardo et al.

standard treatment. Sometimes it is recommended to apply a primary systemic treatment or

even a primary irradiation. Great coordination between the surgical and oncology teams, both
medical and radiotherapeutic, is essential.
Published by Elsevier España, S.L.U. on behalf of SESPM.

PALABRAS CLAVE Diagnóstico y tratamiento locorregional de las pacientes con cáncer de mama durante
Cáncer de mama; la pandemia de la COVID-19
COVID-19;
Resumen Nos enfrentamos a una pandemia que afecta a una parte importante de la población.
Tratamiento
A finales de abril de 2020, en el mundo hay cerca de 3.000.000 de casos, con 205.000 muertes
locorregional;
y 860.000 pacientes recuperados.
Cirugía y radioterapia
La respuesta a esta pandemia en muchos casos ha supuesto modificaciones importantes en el
cuidado diario de las pacientes con cáncer, dependiendo el buen resultado en buena parte del
ajuste de los protocolos a las circunstancias especiales y a los tratamientos multidisciplinarios.
Presentamos una revisión del tratamiento quirúrgico y de radioterapia junto con las recomen-
daciones de los autores basadas en su experiencia personal a la hora del diagnóstico y
tratamiento locorregional del cáncer de mama durante la pandemia del COVID-19.
Los comités multidisciplinarios deben seguir reuniéndose semanalmente en formato de video-
conferencia. Todas las intervenciones quirúrgicas e irradiaciones deben ser llevadas a cabo con
la máxima seguridad tanto para las pacientes como para el personal sanitario que participa.
Publicado por Elsevier España, S.L.U. en nombre de SESPM.

Introduction The response necessitated by this novel situation has

The current outbreak of the novel severe acute respiratory
syndrome coronavirus (SARS-CoV-2; ‘‘COVID-19’’) has spread
worldwide from an epicenter in the Hubei Province of the
People’s Republic of China. By the end of April 2020, there
were more than 3,000,000 cases with 205,000 deaths and
860,000 recovered patients was recognized as a pandemic
by the World Health Organisation (WHO). COVID-19 was rec-
ognized on the 11th of March 2020 and had led to worldwide
repercussions in healthcare delivery.
Early data from China has shown that up to 10% of
hospitalized patients require critical care, usually in the
intensive care unit (ICU) and hospitals have had to reor-
ganize their services to attend to this severe increase in
demand. Men are more likely to be affected than women,
with 69.2% of mortality recorded in men. In women, the
average age of mortality was demonstrated to be more
advanced; 82 years vs 78 years respectively.1
During the weeks after the appearance of COVID-19,
there have been considerable repercussions to cancer care,
including breast cancer services. Specialist surgical and
oncological evaluation of breast cancer patients has faced
multiple issues, impacting on the diagnosis and treatment
of patients with breast cancer.
Patients with diagnosed cancer have an increased risk of
infection when compared to the general population as they
are immunocompromised by the malignancy and indeed by
oncological therapy and surgical procedures.2 Additionally,
should they develop an infection, the overall prognosis is
worse, with higher ICU admission, mechanical ventilation
requirements and mortality.3
resulted in modification of the routine care of breast can-
cer patients. The success of this will depend largely on
the appropriate use of multidisciplinary diagnostic pathways
and treatment protocols, and the adjustment of turnaround
times in every hospital to these special circumstances.4
In those breast units housed in independent buildings out-
side of the main hospital, no outstanding measures were
needed as the premises were COVID-19 free. However, most
hospitals have had to adapt to the special circumstances,
including lack of resources, operating theater capacity
rooms (respirators moved to ICU units), and staff being
affected by the disease. This presented a difficult situation
without a clear deadline.
Indeed multidisciplinary team (MDT) meetings had to
occur regularly, abiding to the physical current restrictions,
with only one person per specialty, maintaining a safe dis-
tance and wearing surgical masks. As physical MDT meetings
have been difficult to organize in the majority of hospitals,
the use of cloud platforms for video and audio conferences
were utilized.
In this manuscript we present a review of locoregional
treatment of breast cancer; surgery and radiotherapy. This
comprises authors personal recommendations based on own
experiences during the COVID-19 outbreak in accordance
with international proposals.
Breast cancer diagnosis
The patient should ideally only attend a single appointment
when there is a suspicion of breast cancer that needs to
be evaluated or when the diagnosis has been confirmed.

Please cite this article in press as: Pardo R, et al. Diagnosis and locoregional treatment of patients with breast cancer
during the COVID-19 pandemic. Rev Senol Patol Mamar. 2020. https://doi.org/10.1016/j.senol.2020.04.002
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Diagnosis and locoregional treatment of breast cancer during COVID-19 pandemic
This would likely result in an agreed management plan
after explaining the MDT decision, with either inclusion
onto the surgical ‘waiting list’ following signed informed
consent, or referred onto medical oncology services for pri-
mary/neoadjuvant treatment.
Patients with benign biopsy results should be contacted
by phone to arrange an appointment for possible follow up
or discharge from the Unit. Many patients feel overwhelmed
by the situation and are weary of attending face-to-face
appointments at the Hospital, which should be respected. If
the biopsy results are non-conclusive and further comple-
mentary or interventional investigations are needed they
will be requested. If these further studies yield benign
results, they should be given by telephone.
Elderly and frail patients, especially those in nursing
homes, with a breast lump are at highest risk of COVID-19,
and it is recommended that they would not be evaluated
at the hospital until the situation is over. Should a face-to-
face appointment be required, ideally no accompanying care
giver should be in attendance.
It is very important to minimize the contagion. All the
staff must wear appropriate personal protective equip-
ment (PPE) according to local protocol (i.e. surgical masks,
gowns and eye protection) and maintain social distancing. If
physical examination is needed, it should be performed with
gloves followed by hand wash with soap for 20 s. Staff and
patient safety should be a priority at all times.5
In order to ensure patient and staff safety, breast screen-
ing programs and genetics counseling clinics/family history
screening should be deferred until the end of the pandemic.6
All efforts should be made to avoid delayed diagnosis in
those patients with suspicious clinical symptoms or imag-
ing findings BIRADS 5 (high priority) or BIRADS 4 (medium
priority) as these potentially impact cancer outcomes.7
In the current situation, it is strongly recommended that
a clip is placed in any suspicious breast lesion during the first
core biopsy, whether it is palpable or not, in order to avoid
repeating this invasive procedure once the final pathology
report is obtained.8
Breast MRI should only be used for special cases in non-
infected patients in order to primarily protect the patient
from infection, and also to reduce the tedious disinfecting
process of the MRI Units.9
Locoregional treatment: surgery
Every hospital, health system and breast surgeon should
review their activity to organize, postpone or cancel planned
breast operations or invasive procedures.
If SARS-CoV-2 tests are available, as they should always
be, all patients should be tested 48 h before the operation
by PCR. If PCR is positive, the operation will be cancelled,
and PCR will be repeated again depending on local pro-
tocols. The surgery will be planned accordingly when a
negative SARS-CoV-2 test result has been achieved. Only a
complete surgical team (anesthetists, surgeons, nurses, aux-
iliary nurses and porters) who are not symptomatic or have
been in contact with an infected individual will perform the
operation, ensuring patient safety.
If the surgical procedure can be deferred without com-
promising oncological outcomes, this should be considered.
Please cite this article in press as: Pardo R, et al. Diagnosis and locoregional treatment of patients with breast cancer
during the COVID-19 pandemic. Rev Senol Patol Mamar. 2020. https://doi.org/10.1016/j.senol.2020.04.002
3
It is essential to bear in mind that the immunosuppressive
nature of both surgery and chemotherapy, may confer onto
the patient an increased risk of infection compared to those
without treatment.
Difficult decisions are taken daily, not only from
oncological but also from ethical perspectives about which
patients should have immediate surgery or which patients
should have deferred surgery. One of the primary challenges
of this situation is to organize and to adapt the breast units
to the evolving situation without knowing when it will come
to an end.
It may be taken into consideration when organizing treat-
ment, that a 60-day delay in surgical treatment in stage I
and II breast cancer has no impact on the prognosis of the
patient, from the oncological point of view.10
Surgical phases during the COVID-19
pandemic11
PHASE I: few COVID-19 admitted patients and most
hospital resources available
Surgery should be considered to patients likely to have
decreased survival if surgery is not performed within
3 months:
• Patients completing neoadjuvant treatment
• Patients with tumours that are T2 or N1 Estrogen Receptor
positive (ER)/Progesterone Receptor positive (PR) Human
epidermal growth factor receptor 2 negative (HER2−)
• Patients with Triple negative or HER2 positive cancer
• Discordant radiology---pathology
• Patients with local recurrence
• For patients with triple negative/HER2 positive cancer,
T1N0M0 should be considered as high priority for surgical
intervention. The MDT should decide if T1 patients can
receive neoadjuvant therapy
After neoadjuvant chemotherapy
1. Hormone receptor positive invasive carcinoma
• If partial or complete response is obtained, hormonal
therapy can be continued to delay surgery by 4---8
weeks. Assess for progression every 2 weeks by telephone
follow-up.
• If ER positive and HER2 positive, hormonal therapy can be
added to and anti-HER2 targeted therapy to defer surgery
by 4---8 weeks with telephone follow-up every two weeks
to assess for progression
2. Triple negative/HER2 + invasive
• Defer surgery 4---8 weeks. It will be considered priority
surgery when the situation returns to normal
3. Reconstruction with autologous tissue should be
deferred. If immediate reconstruction needs to be done,
direct prothesis or expander should be the surgery of
choice.
4. Encourage use of breast conserving surgery whenever
possible, taking onto account availability/applicability of
adjuvant radiotherapy.
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4 R. Pardo et al.
Patients that may have deferred surgery include
• Excision of benign lesions
• Discordant radiology---pathology lesions likely to be benign
• High risk lesions --- atypia, papilloma.
• Prophylactic mastectomy, risk-reducing surgery, and
second stage of two-stage reconstructions should be
deferred to a minimum of three months
• Sentinel node biopsy for incidental infiltrative cancer
identified on excisional biopsy
• cTisN0 lesions --- whether ER positive or negative
• DCIS
1. ER positive DCIS can be treated with hormone therapy
(Tamoxifen or Aromatase inhibitors) with telephone
follow-up every 4 weeks to assess for progression
2. Small volume of ER negative DCIS without radiological sus-
picion of infiltrative disease can have deferred treatment
and be followed up every 4 months
3. Large volume DCIS, which is ER negative, high grade or
palpable can be deferred with a strict MDT follow up every
4 weeks to detect new lumps or nipple discharge. These
patients will be considered as high priority for surgery
when the situation return to normal
• Surgery for re-excision of margins
• Tumors responding to neoadjuvant hormonal treatment
• T1N0 ER positive PR positive/HER2 negative cancers
• Inflammatory and locally advanced breast cancer having
neoajuvant therapy
Non-surgical treatment to be considered, if resources
are available
1. Patients with T1N0 ER positive PR positive HER2 negative
cancer can receive hormonal therapy.
2. Patients with Triple negative and HER2 positive cancer
can undergo neoadjuvant therapy
3. Inflammatory carcinomas and locally advanced tumors
should receive neoadjuvant therapy
PHASE II: rapidly escalating phase. Large volume of
hospital admissions due to COVID-19, requiring ICU
care. Ventilators in limited capacity and shortage
of theater facility
Surgery should be restricted to patients with compromised
overall survival if the procedure is not performed within the
next few days.
Autologous reconstruction should be deferred.
Patients to have surgery as soon as possible:
• Drainage of breast abscess
• Evacuation of hematomas
• Review of an ischemic mastectomy flap
• Revascularization/review of an autologous tissue flap
The rest of breast procedures should be deferred.
Alternative treatments recommended if resources
available:
• Consider neoadjuvant therapy for eligible patients as
defined above
• Observation for the remaining cases with telephone
follow-up every two weeks
Please cite this article in press as: Pardo R, et al. Diagnosis and locoregional treatment of patients with breast cancer
during the COVID-19 pandemic. Rev Senol Patol Mamar. 2020. https://doi.org/10.1016/j.senol.2020.04.002
PHASE III: all hospital resources dedicated to COVID,
only emergency surgery theatre capacity available
Surgery should only be performed when patient survival is
compromised if not operated within hours:
• Drainage of breast abscess
• Evacuation of hematomas
• Revision of an ischemic mastectomy flap
• Revascularization/revision of an autologous tissue flap
Emergency cases that should be considered for surgery in
this phase:
• Disease that has progressed during primary treatment
• Angiosarcomas
• Malignant Phyllodes
Locoregional treatment: radiotherapy
Radiotherapy provision during the COVID-19 pandemic faces
two main challenges. Firstly, to minimize patient contagion
without compromising oncology results, as patients under-
going radiotherapy have an increased risk of infection. The
second issue is related to the limitation of resources, which
in a large number of hospitals have been dedicated to
COVID-19 control. Deferring of surgical procedures will
result in patients presenting to radiotherapy services poten-
tially with a two- or three-month delay. This is an important
management problem as patients with breast cancer repre-
sent 30% of those having radiotherapy.12
Measures during the pandemic and post pandemic
have been anticipated. The European (ESTRO)13 and the
American societies (ASTRO) have designed different strate-
gies that span from deferring to avoiding radiation in
selected cases and the use of ultra-short irradiation schemes
or even preoperative irradiation.
Avoiding radiotherapy
International guidelines recommend omission of radio-
therapy after an informed consent in patients when14 :
• Patients are older than 70
• Tumor is less than 20 mm
• Tumor is Grade I
• There is no angio-lymphatic or perineural invasion
• ER positive PR positive HER2 negative
• Ki67 < 10%
• The patient must be aware that there can be an increase
in local recurrence.
• The patient will always receive hormone therapy
Radiotherapy can also be omitted in patients with low or
medium grade DCIS including non-palpable tumors, less than
25 mm in size and with free margins. Special attention will
be considered in patients younger than 40 years old as they
have an increased risk of recurrence.15
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Diagnosis and locoregional treatment of breast cancer during COVID-19 pandemic
Delay radiotherapy
The irradiation can be deferred as much as 12 weeks in new
patients after surgery.15
Hypofractionated radiotherapy scheme (15---16
fractions)
Despite there being a variability in the treatment choice,16
hypo-fractioned radiotherapy is a standard method17,18 in
many Spanish centers. Therefore, it should be considered as
the first-choice treatment for any breast cancer,19 including
post-mastectomy, nodal irradiation20 or even after immedi-
ate reconstruction.
In the same way, it is advisable to perform boost with
hypofractionation21 or even integrated with whole breast
irradiation protocol and complete the treatment in 15 frac-
tions.
Ultra-short schedules (5---7 fractions)
The Spanish Group of Oncology Radiotherapy (GEORM)
recommends the implementation of ultra-short schedules
without skipping irradiation to any patient that should
receive it in the original protocols.
Whole breast and node irradiation
This group has elaborated the RHEMA protocol based in
results obtained from UK FAST Trial,22,23 UK FAST FORWARD
trial24,25 and HAI-5.26 A 26 Gy dose is given in a 5 daily
fractions scheme of 5.2 Gy and 29 Gy at the tumor bed
with a integrated boost dose of 5.8 Gy. This protocol is
initially considered for Tis-T3N0 tumors, but it can be
also considered for node irradiation. It is important to
highlight that this ultra-short schemes require special tech-
niques as high conformational radiotherapy including IMRT
(Intensity modulated radiotherapy) or VMAT (Volumetric
Intensity-Modulated Arc Therapy) and IGRT (Image Guided
Radiotherapy) that will verify daily position of the patient
before every session.
Partial irradiation of the breast
In selected patients and according to the criteria defined
by cooperative groups GEC-ESTRO and ABS-ESTRO partial
irradiation of the breast can be considered intraopera-
tively after tumorectomy/quadrantectomy with external
radiotherapy27,28 with a five 6 Gy fractions for a 30 Gy dose
or 37.5 Gy in 3.75 Gy per fraction delivered twice daily29 on
the tumor bed with negative margin.
Conditions to be met are:
• Patient age over 50 years
• Tumor less than 3 cm
• Clear excision margins
• No positive nodes
• Grade I-II
• Luminal A biological type breast cancer
Please cite this article in press as: Pardo R, et al. Diagnosis and locoregional treatment of patients with breast cancer
during the COVID-19 pandemic. Rev Senol Patol Mamar. 2020. https://doi.org/10.1016/j.senol.2020.04.002
5
Brachiotherapy can also be an alternative but it is not
available in all centers during the pandemic.
Preoperative irradiation
Delay in surgery secondary to the pandemic will result in a
delay in local treatment, which is essential for disease con-
trol. Preoperative radiotherapy emerges as an interesting
alternative based in published research studies. Pathological
response may be obtained with preoperative irradiation.30,31
It will allow an oncologically-safer delay in surgery, improve
prognosis and facilitate systemic treatment combination.
The GEORM preoperative irradiation protocol is named
RAPOCAMA, where 40.5 Gy are delivered in 2.7 Gy fractions
in the breast with 54 Gy concomitant boost delivered 3.6 Gy
daily.
This protocol can be used concomitantly with taxanes,
anti-HER2 or hormonal therapy. It cannot be concomitant
with anthracyclines. If they are required, the suggested
protocol is radiotherapy first, and then taxanes and anthra-
cyclines. In selected cases in can be shortened to 26 Gy in
breast in five 2.6 Gy fractions and concomitant 29---30 Gy
boost in 5.7---5.8 Gy fractions at the tumor bed with concomi-
tant hormonal therapy. With this preoperative alternative,
surgery can be deferred for 20 weeks.
Finally, for elderly patients32 without indication for
surgery a hypofractionated radiotherapy scheme is proposed
with weekly 6.5 Gy dose delivered for 5 weeks for a total
of 32.5 Gy. A boost of two 6.5 Gy fractions can be added
to the scheme. In this case and if axillary nodes are to be
included 5.5 Gy fractions will be delivered up to a total dose
of 27.5 Gy.
Conclusions
Breast units are facing new scenarios and unprecedented
situations during the pandemic. Protocols have been
adapted to the changing situation, placing patient safety and
oncological care of paramount importance. These patients
not only have a diagnosis of breast cancer but also suffer
a lockdown with restrictions to communicate and to move
freely, adding an increase of anxiety.
Multidisciplinary team meetings should be continued and
performed ‘virtually’ or restricted to one member by spe-
cialty if videoconferencing facilities are not available. The
patient should be informed accordingly about the COVID
situation and the decisions taken.
All surgical and radiotherapy procedures must be per-
formed with the highest level of patient and staff safety.
Many breast units may have to change their protocols,
and we should not ignore the future impact that those
changes will have on our patients. Notwithstanding, our duty
is to minimize this impact as much as possible. We have to
be proactive and to learn from positive consequences that
can be applied to future protocols.
During these months the importance of local and national
leadership in every specialty has been raised as an essential
measure to reorganize the activity to achieve optimal safety
and efficiency.
Looking toward the future, many research lines are now
open not only focusing on the impact of COVID-19 in the
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6 R. Pardo et al.
diagnosis and treatment of breast cancer, but also on the
opinion of how patients have experienced this extreme
situation. Study of PREMS (Patient Reported Experience Mea-
sure) and PROMS (Patient Reports Outcome Measure) will
be determinant to prepare for future actions and improve
patient cancer care.
Additionally, two important questions remain to be
answered by our future research work:
• Will there ever be a return back to normality?
• Will protocol modification remain after the pandemic as
standard treatments?
Conflict of interest
Ricardo Pardo, Manel Algara and Angel Montero are associ-
ated editors at the Journal. Antonio Piñero is co-editor in
chief at the Journal.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at doi:10.1016/j.senol.
2020.04.002
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Please cite this article in press as: Pardo R, et al. Diagnosis and locoregional treatment of patients with breast cancer
during the COVID-19 pandemic. Rev Senol Patol Mamar. 2020. https://doi.org/10.1016/j.senol.2020.04.002